Fifty percent of post-operative patients report inadequate pain relief. Fifty percent of all cancer patients and ninety percent of advanced cancer patients experience pain. Pain is now defined as “the fifth vital sign” as part of the mandate by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to develop guidelines for pain management.
Adequate pain control requires the appropriate medication for the pain level and pain type reported. In a hospital setting, pain medication can be obtained only by a physician's order. Pain medications such as narcotics and non-steroidal medications (and anxiety medications such as tranquilizers) are frequently ordered on an as-needed basis (referred to as pm orders). This approach requires the patient to initiate a request for each pm drug dose. The nurse determines whether the appropriate time interval has passed between doses, according to the physician's order. If the required time interval has elapsed the nurse transports the medication to the patient's bedside and administers the medication to the patient. In some dosing regimens, the patient is given a time-release pain medication at the same time(s) each day, with as-needed (pm) medications for breakthrough pain. Again, the patient must request the medication for each breakthrough pain episode. A common reported patient frustration is the need to issue a request for each and every dose of pm medication. Thus, a busy nurse must determine that the ordered time has elapsed from the last dosage, locate the medication and transport it to the patient in response to each request. This must also be accomplished in a timely fashion, as patients in pain must be administered to as soon as possible.
The as-needed prescription approach dispenses the minimum medication dose on a schedule that can control pain symptoms without the risk of abuse, overdosing or unnecessary side effects. Disadvantageously, in a hospital or institutional setting each medication that is dispensed on a pm basis requires nursing staff time and extra documentation by nursing and pharmacy staff, since the drugs can be administered only after the lapse of the predetermined time interval between doses. For example, a drug prescribed as needed every six hours may be given no more than four times in 24 hours. Such a drug may be administered from zero to four times in any given 24-hour period, depending upon patient dosage requests. If six hours have passed since the last administration of the drug, the medication is provided to the patient in response to the request. If six hours have not lapsed, the patient must wait the minimum time interval of six hours prior to receiving the next drug dose. In a home pm medication, dosing situation the patient must know when the previous dose was administered and await the prescribed interval before administering the next dose.
Improved patient pain control leads to better patient outcomes in the hospital setting. This has been well documented in the surgical literature in the post-operative setting, with fewer post-operative complications, earlier rehabilitation, and shorter hospital stays for patients with better pain management. Better pain management is also highly cost effective since earlier discharges and fewer complications save health care dollars and staff time.